Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy
A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes
- David M. Nathan, MD1,
- John B. Buse, MD, PhD2,
- Mayer B. Davidson, MD3,
- Ele Ferrannini, MD4,
- Rury R. Holman, FRCP5,
- Robert Sherwin, MD6 and
- Bernard Zinman, MD7
- From the 1Diabetes Center, Massachusetts General Hospital, Boston, Massachusetts; the 2University of North Carolina School of Medicine, Chapel Hill, North Carolina; the3 Clinical Center for Research Excellence, Charles R. Drew University, Los Angeles, California; the4 Department of Internal Medicine, University of Pisa, Pisa, Italy; the 5Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University, Oxford, U.K.; the 6Department of Internal Medicine and Yale Center for Clinical Investigation, Yale University School of Medicine, New Haven, Connecticut; and the 7Samuel Lunenfeld Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
- Corresponding author: David. M. Nathan, dnathan{at}partners.org.
The consensus algorithm for the medical management of type 2 diabetes
was published in August 2006 with the expectation that it would be updated,
based on the availability of new interventions and new evidence to establish
their clinical role. The authors continue to endorse the principles used to
develop the algorithm and its major features. We are sensitive to the risks of
changing the algorithm cavalierly or too frequently, without compelling new
information. An update to the consensus algorithm published in January 2008
specifically addressed safety issues surrounding the thiazolidinediones. In
this revision, we focus on the new classes of medications that now have more
clinical data and experience. Diabetes Care 32:193–203,
2009
The epidemic of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity have made the effective treatment of hyperglycemia a top priority.1–3 While the management of hyperglycemia, the hallmark metabolic abnormality associated with type 2 diabetes, has historically taken center stage in the treatment of diabetes, therapies directed at other coincident features, such as dyslipidemia, hypertension, hypercoagulability, obesity, and insulin resistance, have also been a major focus of research and therapy. Maintaining glycemic levels as close to the nondiabetic range as possible has been demonstrated to have a powerful beneficial effect on diabetes-specific microvascular complications, including retinopathy, nephropathy, and neuropathy, in the setting of type 1 diabetes;4,5 in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce microvascular complications.6–8 Intensive glycemic management resulting in lower A1C levels has also been shown to have a beneficial effect on cardiovascular disease (CVD) complications in type 1 diabetes;9,10 however, current studies have failed to demonstrate a beneficial effect of intensive diabetes therapy on CVD in type 2 diabetes. …
